AU2007324432B2

AU2007324432B2 - Methods for improving bioavailability of a renin inhibitor

Info

Publication number: AU2007324432B2
Application number: AU2007324432A
Authority: AU
Inventors: Gian P. Camenisch; Thomas Faller; Gerhard Gross; Isabel Ottinger
Original assignee: Novartis AG
Current assignee: Novartis AG
Priority date: 2006-11-24
Filing date: 2007-11-23
Publication date: 2010-10-14
Anticipated expiration: 2027-11-23
Also published as: EP2094257A1; CN101541318A; WO2008062066A1; EP1927350A1; CA2670160A1; BRPI0719589A2; US20100234467A1; MX2009005247A; RU2009123645A; JP2010510296A; KR20090085121A; AU2007324432A1

Description

WO 2008/062066 PCT/EP2007/062772 -1 METHODS FOR IMPROVING BIOAVAILABILITY OF A RENIN INHIBITOR The oral route is often the most convenient route for drug administration, but unfortunately many therapeutic agents are not orally active due to their poor bioavailability. The bioavailability of many therapeutic agents may be reduced by the action of so-called "efflux pump" proteins which actively eject foreign substances from the cell to give rise, for example, to the multidrug resistance effect. These drug efflux proteins principally comprise MDR (multidrug resistance protein) and MRP (multidrug resistance associated protein) type transporters. Some of the best studied efflux proteins include P-glycoprotein (Pgp or MDR1) and MRP2. Although membrane located efflux proteins are well known as a factors contributing to the acquired multidrug resistance syndrome arising in many cancer patients after repeated chemotherapy, it has only recently been realized that, e.g., MDR1, is also found in the normal tissue such as small intestine, colon, liver and endothelial cells in the blood brain barrier. The presence of such efflux proteins in the gastro-intestinal (GI) tract, especially, in the small intestine and colon, may contribute to the poor bioavailability of many natural product drugs (including the anticancer agents vinblastine and doxorubicin). For example, many chemotherapeutic agents given orally can not show anti-tumor activity due to poor bioavailability and their inability to enter GI tissues. Furthermore, efflux proteins present in hepatocytes may additionally reduce the bioavailability of therapeutic agents by elimination via bile (see Faber et al., Adv. Drug Del. Rev., 55, 107-124, 2003). Orally administered therapeutic agents must overcome several barriers before reaching their target site. The first major obstacle to cross is the intestinal epithelium. Although lipophilic compounds may readily diffuse across the apical plasma membrane, their subsequent passage across the basolateral membrane and into portal blood is by no means guaranteed. Efflux pump proteins located at the apical membrane, which include various drug transporters of the ATP-binding cassette (ABC) family, e.g., ABC transporters such as MDR1, MRP1 and MRP2, may drive compounds from inside the cell back into the intestinal lumen, restricting their oral bioavailability by preventing their absorption into blood. The second major hurdle to face is the liver where drugs are transported passively or by saturable transport processes from the portal blood across hepatocyte plasma (sinusoidal) membranes and bile (canalicular) membranes into bile. Efflux pump proteins located at the WO 2008/062066 PCT/EP2007/062772 -2 canalicular membranes, which again include various drug transporters of the ABC family, e.g., ABC transporters such as MDR1, breast cancer resistance protein (BCRP) and MRP2, may drive drug compounds from inside hepatocytes into the bile, restricting their oral bioavailability by promoting biliary elimination. For example, MDR1 has been demonstrated to transport most HIV protease inhibitors and to reduce their oral bioavailability and lymphocyte, brain, testis and fetal penetration, possibly resulting in major limiting effects on the therapeutic efficacy of these drugs. Therefore, one approach to improve bioavailability may be to co-administer an efflux protein inhibitor, i.e., a compound that inhibits the function of efflux proteins, with a drug substance. In other words, when an efflux protein inhibitor is co-administered with a therapeutic agent which is also a substrate for that specific efflux system, the oral bioavailability and/or the pharmacological active concentrations at the target site of the therapeutic agent may be enhanced by inhibiting the efflux mechanism from inside the cell back into the intestinal lumen and/or by inhibiting secretion into bile. However, efflux proteins exhibit low substrate specificity, and transport many kinds of molecules. The specificity is not rigorously understood, and there is no way of predicting from the molecular structure of a drug substance whether that specific drug will be a substrate for a certain transporter protein. Thus, it is generally not possible to predict whether a particular drug or compound will be subject to the efflux pumping action discussed above. Also, if a particular drug has a low oral bioavailability, it is generally not possible to predict whether the low bioavailability is caused, wholly or partially, by the efflux proteins discussed above, nor can it be predicted whether the low bioavailability can be increased by co-administration of an efflux protein inhibitor (see Chan et al. Eur. J. Pharmaceut. Sci., 21, 25-51, 2004). In WO 2006/013094 discloses the use of a renin inhibitor, such as aliskiren, together with an efflux protein inhibitor, namely, the MDR1 inhibitor PSC833. Despite the advantages conferred by this finding, there is a continuing need for improved and simple systems for enhancing the bioavailability of renin inhibitors. Surprisingly, it has now been found that the bioavailability of many renin inhibitors, e.g., those disclosed in U.S. Patents No. 5,559,111, No. 6,197,959 and No. 6,376,672, can be significantly improved and the inter- and intra-subject variability can be decreased by using -3 not only pharmacologically active substances such as those described in WO 2006/013094, but also non-pharmacological active compounds, including GRAS compounds and excipients, that are MDR1 inhibitors in combination with renin inhibitors. Thus, in one aspect the present invention relates to a pharmaceutical composition comprising (i) a renin inhibitor and (ii) an MDR1 inhibitor selected from a non-pharmacologically active compound. Accordingly, in another aspect the present invention provides a method for improving the bioavailability, preferably, oral bioavailability, of a renin inhibitor, which method comprises co-administering to a mammal, especially a human, in need of such treatment, a combination of a renin inhibitor and an MDR1 inhibitor selected from non pharmacologically active compounds including GRAS compounds and excipients, in particular a GRAS compound. The non-pharmacologically active compound is administered in an amount such that the bioavailability of a renin inhibitor is improved in comparison with what the bioavailability would be in the absence of the an MDR1 inhibitor selected from a non-pharmacologically active compound (e.g. 10 % when administered orally to humans). An MDR1 inhibitor selected from a non-pharmacologically active compound and a renin inhibitor are preferably each co-administered in an amount such that the combination has a desired therapeutic effect, e.g., an anti-hypertensive effect. In particular, in a further aspect the present invention provides a method for improving the bioavailability of a S-amino-y-hydroxy-o-aryl-alkanoic acid derivative, which method comprises co-administering to a mammal, especially a human, in need of such treatment, a combination of a S-amino-y-hydroxy-o-aryl-alkanoic acid derivative, or a pharmaceutically acceptable salt thereof, and an MDR1 inhibitor selected from a non pharmacologically active compound. The present invention also provides a use of a MDR1 inhibitor selected from a non pharmacologically active compound in the manufacture of a medicament for improving the bioavailability of a renin inhibitor, or a pharmaceutically acceptable salt thereof.

- 3A In one embodiment, the non-pharmacologically active compound is a GRAS compound selected from the group consisting of curcumin, phenyl cinnamate, coumarin, beta-amyrin cinnamate, apiole, bergamottin, caffein, 8-(decylthio-)caffeine, 8-benzyl-caffeine, diethylpyrocarbonate, morin, narirutin, piperine, quercetin, salvinorin, silybin, theobromin, 5 vanillin, and vanillyl-N-nonylamide. Figure 1 shows the effect of the renin inhibitor Aliskiren on the ATPase activity in membrane vesicles expressing high levels of MDR1. Figure 2 shows bi-directional transport of the renin inhibitor Aliskiren across Caco-2 cell monolayers in the apical (AP) to basolateral (BL) and BL-to-AP direction.

WO 2008/062066 PCT/EP2007/062772 -4 The term "co-administration" of a combination of a renin inhibitor, in particular, a 6-amino-y hydroxy-co-aryl-alkanoic acid derivative, and an MDR1 inhibitor selected from a non pharmacologically active compound means that the two components can be administered together as a pharmaceutical composition or as part of the same, unitary dosage form. Co administration also includes administering a renin inhibitor, in particular, a 6-amino-y-hydroxy o-aryl-alkanoic acid derivative, and an MDR1 inhibitor selected from a non-pharmacologically active compound separately but as part of the same therapeutic regimen. The two components, if administered separately, need not necessarily be administered at essentially the same time, although they can if so desired. Thus, co-administration includes, for example, administering a renin inhibitor, in particular, a 6-amino-y-hydroxy-o-aryl-alkanoic acid derivative, plus a an MDR1 inhibitor selected from a non-pharmacologically active compound as separate dosages or dosage forms, but at the same time. Co-administration also includes separate administration at different times and in any order. The renin inhibitors to which the present invention applies are any of those having renin inhibitory activity in vivo and, therefore, pharmaceutical utility, e.g., as therapeutic agents for the treatment of hypertension, congestive heart failure, cardiac hypertrophy, cardiac fibrosis, cardiomyopathy postinfarction, complications resulting from diabetes, such as nephropathy, vasculopathy and neuropathy, diseases of the coronary vessels, restenosis following angioplasty, raised intra-ocular pressure, glaucoma, abnormal vascular growth, hyperaldosteronism, anxiety states and cognitive disorders. In particular, the present invention relates to 6-amino-y-hydroxy-o-aryl-alkanoic acid amide derivatives as disclosed in U.S. Patent No. 5,559,111. A renin inhibitor, in particular, a 6-amino-y-hydroxy-o-aryl-alkanoic acid derivative, of the present invention may be employed in the form of its pharmaceutically acceptable salts, in an anhydrous form or a hydrate or a solvate thereof. All such forms are useful within the scope of the present invention. Preferably, a 6-amino-y-hydroxy-o-aryl-alkanoic acid derivative of the present invention having the formula WO 2008/062066 PCT/EP2007/062772 -5 OH R4 H 2N,,," N NH 2 R 2 R3 wherein R 1 is C 14 alkoxy-C 14 alkoxy or C 14 alkoxy-C 14 alkyl; R 2 is C 14 alkyl or C 14 alkoxy; and

R

3 and R 4 are independently branched C 14 alkyl; or a pharmaceutically acceptable salt thereof; is used. More preferably, a 6-amino-y-hydroxy-o-aryl-alkanoic acid derivative of the present invention having formula (1) wherein R 1 is 3-methoxypropoxy; R 2 is methoxy; and R 3 and R 4 are isopropyl; or a pharmaceutically acceptable salt thereof; most preferably, a 6-amino-y hydroxy-o-aryl-alkanoic acid derivative of the present invention which is (2S,4S,5S,7S)-5 am ino-4-hydroxy-2-isopropyl-7-[4-methoxy-3-(3-methoxy-propoxy)-benzyl]-8-methyl nonanoic acid (2-carbamoyl-2-methyl-propyl)-amide hemifumarate, also known as Aliskiren, is employed. The term "MDR1 inhibitor" as used herein is intended to encompass efflux protein inhibitors, namely inhibitors of multidrug resistance protein type transporters. The term "efflux protein inhibitor" as used herein refers to any compound, a pharmaceutical or an excipient compound, that inhibits the action of a ABC transporter, e.g. those disclosed in Bakos et al. Mol PharmacoL, 57, 760-768 (2002) and Maarten et al. AIDS, 16, 2295-2301 (2002). Additional information on efflux protein inhibitors can be found in WO 2006/013094. The term "non-pharmacologically active compound" as used herein is defined according to the EMEA guidelines as a compound which is not pharmacodynamically active at the dose at which it is administered to the target, such as the mammal, including the human, by means of a medicinal product in which it is included, but it may be capable of pharmacological action when incorporated at a different concentration in another product. Thus, the MDR1 inhibitor selected from a non-pharmacologically active compound possess, when employed in accordance with the present invention, no other pharmacological action than the MDR1 inhibition. The term "GRAS compound" as used herein is a commonly employed term used by the health authorities, in particular the FDA, and is the acronym for Generally Recognized As WO 2008/062066 PCT/EP2007/062772 -6 Safe. It is a specifically-designated regulatory category for conventional foods. Ingredients added to conventional foods must be approved as food additives or be GRAS, both of which assure "reasonable certainty" of safety. In general, GRAS compounds are non-toxic and themselves not pharmacologically active. In this context, the term "non-pharmacologically active" means that the GRAS compounds themselves, at least in the amount and concentration in which they are employed, do not to cure or reduce symptoms of an illness or medical conditions. Ingredients commonly used in food prior to 1958, when the Food Additives Amendment was added to the Federal Food, Drug and Cosmetic Act (FFDCA), are automatically GRAS, as are substances for which relative scientific agreement exists as to the safety. In 1997, a GRAS self-affirmation notification process was proposed; while it has not been finalized, FDA is operating under the aegis of the rule with industry buy-in. The GRAS process is now essentially an independent process with the same safety requirements as food additives, but without FDA approval. In the process of self-affirmation, companies work to assemble a comprehensive dossier of scientific substantiation and historical documentation supporting the safe use of the compound. Because of the requirement of "general recognition", the pivotal data for safety substantiation must be part of the public domain. During the review process, companies work to define particular food categories of interest as well as the usage levels for those categories. The final determination by an expert panel includes reviewing technical evidence about the safety of the ingredient for its intended use and common knowledge about the safety of the ingredient, with the data providing "reasonable certainty" of safety. The health authorities regularly publish lists of GRAS compounds. The term "excipient" as used herein is defined according to the EMEA guidelines as a constituent of a pharmaceutical form or medicinal product, other than the active substance. Thus, an excipient is an inactive constituent used as a carrier for the active substance of the medicinal product. Excipients can be used to aid the manufacturing process of the medicinal product, ease administration of the medicinal product by bringing it into an appropriate form or to bulk up formulations to allow for convenient and accurate dosage. The non-pharmacologically active compounds suitable for the pharmaceutical composition in accordance with the present invention can be any non-pharmacologically active compound which is an MDR1 inhibitor. Preferably the non-pharmacologically active compounds are GRAS compounds and excipients which are MDRI inhibitors.

WO 2008/062066 PCT/EP2007/062772 -7 Typically, non-limiting examples of GRAS compounds that are MDR1 inhibitors include: Curcumin

OCH

3 HO OH N 00H 3 ; 0 0 Phenyl cinnamate 0 CH=CH-C-0 Cou marin N N Beta-amyrin cinnamate CH =CH-C- O / \ Hc- Apiole Bergamottin WO 2008/062066 PCT/EP2007/062772 -8

CH

3

CH

3 eCH, Caffein CH3 H NCX N QAI N CHa Caffeine, 8-(Decylthio-) Caffeine, 8-benzyl Diethylpyrocarbonate Morin HO OH HO N 0 N I I OH OH O Narirutin Piperine -9 N Quercetin OH 0OH- xH20 OHH HO0 OH Salvinorin Silybin Theobromin o

CH

3 OH HN H > Vanillin O H

OCH

3 OH and Vanillyl-N-nonylamide WO 2008/062066 PCT/EP2007/062772 - 10 Typically, non-limiting examples of excipients which are MDR1 inhibitors include surfactants, in particular non-ionic surfactants, as listed below: 1) Reaction products of a natural or hydrogenated castor oil and ethylene oxide . The natural or hydrogenated castor oil may be reacted with ethylene oxide in a molar ratio of from about 1:35 to about 1:60, with optional removal of the polyethylene-glycol component from the products. Various such surfactants are commercially available. Particularly suitable surfactants include polyethyleneglycol-hydrogenated castor oils available under the trade name Cremophor@; Cremophor@ RH 40, which has a saponification value of about 50 to 60, an acid value less than about 1, a water content (Fischer) less than about 2%, an no 60 of about 1.453- to 1.457 and an HLB of about 14 14-to 16; and Cremophor@ RH 60, which has a saponification value of about 40- to 50, an acid value less than about 1, an iodine value of less than about 1, a water content (Fischer) of about 4.5- to 5.5%, an no 60 of about 1.453 453-to 1.457 and an HLB of about 15 to 17. An especially preferred product of this class is Cremophor@ RH40. Other useful products of this class are available under the trade names Nikkol@ (e.g. Nikkol@ HCO-40 and HCO-60), Mapeg@ (e.g. Mapeg@ CO-40h), Incrocas@ (e.g. Incrocas@ 40), Tagat@ (for example polyoxyethylene-glycerol-fatty acid esters e.g. Tagat@ RH 40) and Simulsol OL-50 (PEG-40 castor oil, which has a saponification value of about 55 to 65, an acid value of max. 2, an iodine value of 25 to 35, a water content of max. 8%, and an HLB of about 13, available from Seppic). These surfactants are further described in Fiedler loc. citloc. cit.. Other suitable surfactants of this class include polyethyleneglycol castor oils such as that available under the trade name Cremophor@ EL, which has a molecular weight (by steam osmometry) of about 1630, a saponification value of about 65 to 70, an acid value of about 2, an iodine value of about 28 to 32 and an n 25 of about 1.471. 2) Polyoxvethylene-sorbitan-fatty acid esters These include , for example mono- and tri-lauryl, palmityl, stearyl and oleyl esters of the type known and commercially available under the trade name Tween@ (Fiedler, loc. cit. loc. cit. p.1615 ff) from Uniqema including the products: WO 2008/062066 PCT/EP2007/062772 - 11 Tween@ 20 [polyoxyethylene(20)sorbitanmonolau rate], Tween@ 21 [polyoxyethylene(4)sorbitanmonolaurate], Tween@ 40 [polyoxyethylene(20)sorbitanmonopalmitate], Tween@ 60 [polyoxyethylene(20)sorbitanmonostearate], Tween@ 65 [polyoxyethylene(20)sorbitantristearate], Tween@ 80 [polyoxyethylene(20)sorbitanmonooleate], Tween@ 81 [polyoxyethylene(5)sorbitanmonooleate], and Tween® 85 [polyoxyethylene(20)sorbitantrioleate]. Especially preferred products of this class are Tween@ 20 and Tween@ 80. 3) Polvoxvethylene-polvoxvpropylene co-polymers and block co-polymers or, poloxamers These include, for example of the type known and commercially available under the trade names Pluronic@ and Emkalyx@ (Fiedler, loc. cit.loc. cit., 2, p. 1203). An especially preferred product of this class is Pluronic@ F68 (poloxamer 188) from BASF, having a melting point of about 52'C and a molecular weight of about 6800 to 8975. 4) Polvoxvethylene mono esters of a saturated C to C2, These include e.g. C18 substituted e.g. hydroxy fatty acid; e.g. 12 hydroxy stearic acid PEG ester, e.g. of PEG about e.g. 600-900 e.g. 660 Daltons MW, e.g. Solutol@ HS 15 from BASF, Ludwigshafen, Germany. According to the BASF technical leaflet MEF 151E (1986) comprises about 70% polyethoxylated 1 2-hydroxystearate by weight and about 30% by weight unesterified polyethylene glycol component. Solutol HS 15 has a hydrogenation value of 90 to 110, a saponification value of 53 to 63, an acid number of maximum 1, and a maximum water content of 0.5% by weight. 5) Water soluble tocopheryl polvethylene glycol succinic acid esters (TPGS) These include, e.g. those with a polymerisation number ca 1000, e.g. available from Eastman Fine Chemicals Kingsport, Texas, USA. 6) Transesterified, polvoxvethylated caprvlic-capric acid qlycerides WO 2008/062066 PCT/EP2007/062772 - 12 These include for example those that are commercially available under the trade name Labrasol@ from e.g. Gattefosse. Labrasol@ has an acid value of max. 1, a saponification value of 90-110, and an iodine value of max. 1 (H. Fiedler, loc. citloc. cit., vol 2, page 880). Of these non-ionic surfactants, the following are particularly preferred: Vitamin E TPGS, Cremophor EL, Cremophor RH40, Polysorbat 80, Solutol HS15, Pluronic F68, Labrasol. Of these non-pharmacologically active compounds, the following are particularly preferred: Curcumin, Vitamin E TPGS, Piperine, Coumarin, and Phenyl cinnamate. It was surprisingly found that these compounds, when co-administered with a renin inhibitor, such as aliskiren, could significantly increase the bioavailability of this compound and the inter- and intra-subject variability decreased. Due to the increase of bioavailability the amount of drug substance can be significantly decreased and, thus, the costs per medicament. In addition, since these MDR1 inhibitors are by definition non-toxic and non-pharmacologically active, there is no need to perform extensive studies for approval by the health authorities. To the contrary, these non-pharmacologically active compounds will be considered just as excipients and this will further decrease the development time and costs. As disclosed herein above, a renin inhibitor, in particular, a 6-amino-y-hydroxy-o-aryl alkanoic acid derivative, and an MDR1 inhibitor selected from a non-pharmacologically active compound can be co-administered as a pharmaceutical composition. The components may be administered together in any conventional dosage form, usually also together with a pharmaceutically acceptable carrier or diluent. For oral administration the pharmaceutical composition comprising a renin inhibitor, in particular, a 6-amino-y-hydroxy-o-aryl-alkanoic acid derivative, and an MDR1 inhibitor selected from a non-pharmacologically active compound can take the form of solutions, suspensions, tablets, pills, capsules, powders, microemulsions, unit dose packets and the like. Preferred are tablets and gelatin capsules comprising the active ingredient together with: a) diluents, e.g., lactose, dextrose, sucrose, mannitol, sorbitol, cellulose and/or glycine; b) lubricants, e.g., silica, talcum, stearic acid, its magnesium or calcium salt and/or polyethyleneglycol; for tablets also c) binders, e.g., magnesium aluminum silicate, starch paste, gelatin, tragacanth, methylcellulose, sodium carboxymethylcellulose and or polyvinylpyrrolidone; if desired d) disintegrants, e.g., starches, agar, alginic acid or its sodium WO 2008/062066 PCT/EP2007/062772 - 13 salt, or effervescent mixtures; and/or e) absorbants, colorants, flavors and sweeteners. Injectable compositions are preferably aqueous isotonic solutions or suspensions, and suppositories are advantageously prepared from fatty emulsions or suspensions. Said compositions may be sterilized and/or contain adjuvants, such as preserving, stabilizing, wetting or emulsifying agents, solution promoters, taste masking agents, salts for regulating the osmotic pressure and/or buffers. In addition, they may also contain other therapeutically valuable substances. Said compositions are prepared according to conventional mixing, granulating or coating methods, respectively, and contain about 0.1 75%, preferably about 1-50%, of the active ingredient. More specifically, the present invention provides a pharmaceutical composition comprising a therapeutically effective amount of a renin inhibitor, preferably, a 6-amino-y-hydroxy-o-aryl alkanoic acid derivative, in combination with an MDR1 inhibitor selected from a non pharmacologically active compound, said an MDR1 inhibitor selected from a non pharmacologically active compound being preferably present in an amount such that, following administration, the bioavailability of a renin inhibitor is improved by at least 5 %. Preferably, a pharmaceutical composition of the present invention comprises a 6-amino-y hydroxy-o-aryl-alkanoic acid derivative of the formula OH R4 H 2N,,,N NH 2 R22 R3 wherein R 1 is C 14 alkoxy-C 1 4 alkoxy or C 14 alkoxy-C 14 alkyl; R 2 is C 14 alkyl or C 14 alkoxy; and

R

3 and R 4 are independently branched C 14 alkyl; or a pharmaceutically acceptable salt thereof; in combination with a an MDR1 inhibitor selected from a non-pharmacologically active compound. More preferably, a pharmaceutical composition of the present invention comprises a 6 amino-y-hydroxy-o-aryl-alkanoic acid derivative of formula (1) wherein R 1 is 3 methoxypropoxy; R 2 is methoxy; and R 3 and R 4 are isopropyl; or a pharmaceutically acceptable salt thereof; in combination with an MDR1 inhibitor selected from a non pharmacologically active compound.

WO 2008/062066 PCT/EP2007/062772 - 14 Most preferably, a pharmaceutical composition of the present invention comprises (2S,4S, 5S,7S)-5-amino-4-hydroxy-2-isopropy-7-[4-methoxy-3-(3-methoxy-propoxy)-benzyl] 8-methyl-nonanoic acid (2-carbamoyl-2-methyl-propyl)-amide hemifumarate in combination with an MDR1 inhibitor selected from a non-pharmacologically active compound. Preferably, the bioavailability of a renin inhibitor, in particular, a 6-amino-y-hydroxy-o-aryl alkanoic acid derivative, e.g., Aliskiren, or a pharmaceutically acceptable salt thereof, is improved by at least 5 %. Bioavailability of a drug may be assessed as known in the art by measuring AUCs, where AUC is the area under the curve (AUC) plotting the serum or plasma concentration of a drug along the ordinate (Y-axis) against time along the abscissa (X-axis). Generally, the values for AUC represent a number of values taken from all the subjects in a test population and are, therefore, mean values averaged over the entire test population. Co-administration a renin inhibitor and an MDR1 inhibitor selected from a non pharmacologically active compound may also increase Cmax relative to dosing the renin inhibitor in the absence of an efflux protein inhibitor, and this is provided as a further aspect of the invention. Cmax is also well understood in the art as an abbreviation for the maximum drug concentration in serum or plasma of a test subject. Since the present invention has an aspect that relates to treatment with a combination of compounds which may be co-administered separately, the invention also relates to combining separate pharmaceutical compositions in kit form. The kit comprises two separate pharmaceutical compositions: (1) a composition comprising a renin inhibitor, in particular, a 6-amino-y-hydroxy-o-aryl-alkanoic acid derivative, plus a pharmaceutically acceptable carrier or diluent; and (2) a composition comprising an MDR1 inhibitor selected from a non pharmacologically active compound plus a pharmaceutically acceptable carrier or diluent. The amounts of (1) and (2) are such that, when co-administered separately, the bioavailability of a renin inhibitor, in particular, a 6-amino-y-hydroxy-o-aryl-alkanoic acid derivative, is improved preferably by at least 5 %. The kit comprises a container for containing the separate compositions such as a divided bottle or a divided foil packet, wherein each compartment contains a plurality of dosage forms (e.g., tablets) comprising (1) or (2). Alternatively, rather than separating the active ingredient-containing dosage forms, the kit may contain separate compartments each of which contains a whole dosage which in turn comprises separate dosage forms. An example of this type of kit is a blister pack WO 2008/062066 PCT/EP2007/062772 - 15 wherein each individual blister contains two (or more) tablets, one (or more) tablet(s) comprising a pharmaceutical composition (1), and the second (or more) tablet(s) comprising a pharmaceutical composition (2). Typically the kit comprises directions for the administration of the separate components. The kit form is particularly advantageous when the separate components are preferably administered in different dosage forms (e.g., oral and parenteral), are administered at different dosage intervals, or when titration of the individual components of the combination is desired by the prescribing physician. In the case of the instant invention a kit therefore comprises: (1) a therapeutically effective amount of a composition comprising a renin inhibitor, in particular, a 6-amino-y-hydroxy-o-aryl-alkanoic acid derivative, e.g., Aliskiren, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier or diluent, in a first dosage form; (2) a composition comprising an MDR1 inhibitor selected from a non-pharmacologically active compound in an amount such that, following administration, the bioavailability of a renin inhibitor, in particular, a 6-amino-y-hydroxy-o-aryl-alkanoic acid derivative, e.g., aliskiren, or a pharmaceutically acceptable salt thereof, is preferably improved by at least 5 %, and a pharmaceutically acceptable carrier or diluent, in a second dosage form; and (3) a container for containing said first and second dosage forms. Ultimately, the present invention relates to a use of a an MDR1 inhibitor selected from a non pharmacologically active compound, for the manufacture of a medicament to improve the bioavailability, preferably oral bioavailability, of a renin inhibitor, preferably, a 6-amino-y hydroxy-o-aryl-alkanoic acid derivative, e.g., Aliskiren, or a pharmaceutically acceptable salt thereof. The efflux protein(s) involved in the drug efflux of a drug substance may be identified, and the corresponding kinetic parameters may be determined, i.e., Michaelis-Menten Constant and Maximal Drug Transport (Km and Jmax), using methods known in the art, e.g., by an ATPase assay using Sf9 (Spodoptera fruigiperda) membrane vesicles expressing high levels of the selected ABC transporter. In this assay the ABC transporters remove substrates out of cells by using ATP hydrolysis as an energy source. ATP hydrolysis yields inorganic phosphate (Pi), which can be detected by a simple colorimetric reaction. The amount of Pi liberated by the transporter is proportional to the activity of the transporter. Membrane preparations containing ABC transporters show a baseline ATPase activity that varies for different transporters. Transported substrates increase this baseline ATPase activity, while WO 2008/062066 PCT/EP2007/062772 - 16 inhibitors inhibit the baseline ATPase activity and/or the ATPase activity measured in the presence of a stimulating agent. Both, activation and inhibition studies may be performed. As illustrated herein in Example 1 (Figure 1), Aliskiren increases the ATPase activity in membrane vesicles expressing high levels of MDR1 with a Km value of about 3 tM, suggesting that the efflux system involved in Aliskiren transport is possibly MDR1. Alternatively, the in vitro transporter affinity of a drug substance can be determined and approximated by a Caco-2 cell assay as described, e.g., in Camenisch et al., Pharm. Act. Helv. 71, 309-327 (1996), or as illustrated herein in the Examples. The identification of the transporter protein and the efficacy of a compound to inhibit the efflux system involved may as well be determined in the Caco-2 cell assay. For example, Aliskiren is identified as a low to moderate permeable compound (intrinsic permeability < 80%), being additionally a substrate for a prominent efflux system (Figure 2). The above description fully discloses the invention including preferred embodiments thereof. Modifications and improvements of the embodiments specifically disclosed herein are within the scope of the following claims. Without further elaboration, it is believed that one skilled in the art can, using the preceding description, utilize the present invention to its fullest extent. Therefore, the Examples herein are to be construed as merely illustrative and not a limitation of the scope of the present invention in any way. Example 1: ATPase assay Efflux mediated by the human MDR1, is measured by incubating the purified membrane vesicles in the absence and the presence of a stimulating agent (Verapamil [40 .M] for MDR1) with different concentrations of a drug substance [0.046, 0.137, 0.41, 1.23, 3.7, 11.1, 33.3 and 100 tM] in transport buffer at pH 7.4 at 370C. A 5 mM stock solution of the therapeutic agent of interest will be prepared in a common organic solvent, e.g., dimetylsulfoxide, ethanol, methanol and acetonitrile, such a way that addition of the stock solution or its dilutions into assay mixture produces the above mentioned final concentrations, and the organic solvent used is 2 % of the total volume (v/v). All the solutions used in this assay will be maintained at pH 7.4. Membrane vesicles maintained at -800C will be used for the ATPase experiments. Transporter mediated efflux may be determined as described in literature (Sarkadi, B. Price, WO 2008/062066 PCT/EP2007/062772 - 17 E. Boucher, R. Germann, U. and Scarborough, G. J. Biol. Chem. 1992, 267: 4854-4858). Briefly, membrane suspension in the presence and absence of a test drug, stimulating agent, Na 3

VO

4 60 mM and Glutathione 2 mM (only for MRP1 and MRP2 transporters) is pipetted into a 96-well plate and transferred to 370C for 5 min of preincubation. The ATPase reaction is started by addition of 25 mM Mg-ATP solution and subsequent incubation at 370C (20 min for MDR1, 60 min for MRP1 and 30 min for MRP2). Afterwards, the ATPase reaction is stopped by adding SDS (5%) to each incubation. After addition of ammonium molybdate/zinc acetate colorimetric detection reagent the plate is incubated for an addition 25 min at 370C. After incubating the OD is measured at 730 nm. Using a previously determined phosphate standard curve the Pi liberated [nmol/well] can be calculated. OD values will be presented as means ± standard deviations of the experiments performed (n = 2). All statistical analyses are performed using Microsoft EXCEL 5.0c. To calculate the so-called specific (Na 3

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4 sensitive) transporter ATPase activity for each drug and drug-concentration assayed the Pi values determined in the presence of Na 3

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4 have to be subtracted from the Pi values measured without Na 3

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4 . The Na 3

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4 sensitive transporter activity in terms of Pi liberated/mg membrane protein/min can be determined by dividing the numbers by the amount of membrane protein added to each well and the time of incubation in min (Figure 1). Example 2: Caco-2 cell assay Caco-2 cell monolayers grown on PET filters for 21-25 days are used for the transport experiments. The flux of compounds across Caco-2 cell monolayers grown on PET filters as well as across PET filters alone without Caco-2 cells is determined as follows: Prior to the transport experiment, the culture medium in the acceptor compartment (0.2 mL for apical and 1.0 mL for basolateral sides) is replaced with acceptor solution (HBSS, when relevant containing the inhibitor of interest) preincubated at 371C. To start the experiment, the medium in the donor compartment (0.35 mL for apical and 1.15 mL for basolateral sides) is replaced with donor solution (compound in HBSS, when relevant containing inhibitor of interest) pre-incubated at 37'C. Aliquots of 150 pL are removed from the donor and the acceptor side after about 1 and 120 min. Transport experiments in both apical-to-basolateral and basolateral-to-apical directions are performed in triplicate at 37'C in an incubator without WO 2008/062066 PCT/EP2007/062772 - 18 shaking. The suitability of Caco-2 cells for transport experiments is examined by measuring the permeability of [ 3 H]-mannitol at 5 0.1 pM and [ 3 H]-propranolol at 5 0.1 pM from apical to basolateral sides for 120 min in a total of 6 representative cell monolayers (3 for each compound) within the same batch of cells. Radioactive samples are analyzed by liquid scintillation counting. All other non-radiolabeled samples are kept frozen at -20'C until analysis by liquid chromatography/tandem mass spectrometry (LC-MS/MS). Transport values of the compounds tested are determined using the following equation (Artursson et al., Biochem. Biophys. Res. Comm. 175: 880-885, 1991): PaPP - AQ At-A-Co where Papp (cm/min) is the apparent permeability coefficient, AQ is the amount of compound found in the acceptor compartment at time t, At (min) is the incubation time period, Co (pg/mL) is the initial concentration of the compound in the donor compartment and A (cm 2 ) is the surface area of the membrane. For labeled samples, the limit of quantitation (LOQ) is taken as the lowest sample concentration value obtained from the radioactive scale which is significantly higher than the measured blank value and for which the standard error of the measurement is lower than 20 %. Under the conditions of this study, the LOQ of absolute radioactivity is 2 dpm for [14C] labeled Aliskiren corresponding to 12 nmol/L. Papp values are presented as means + standard deviations of the transport experiments performed (n = 3). The statistical significance in differences between any two given data sets is examined by t-test. The probability level for assignment of significance of difference is p < 0.025. All statistical analyses were performed using Microsoft EXCEL 5.0c. For 1 pM concentration of Aliskiren within a time period of 120 min an apical to basolateral transport of about 0.2-10-5 cm/min is detectable. Basolateral to apical transport on the other side occurred with a permeability value of about 10-10-5 cm/min, which is significantly higher than the apical to basolateral transport. For 1, 5, 10 and 50 pM concentration of Aliskiren a gradual increase of apical to basolateral transport is observed, approaching a plateau permeability value of about 7-10-5 cm/min at 10 pM. Basolateral to apical transport on the other side does not change significantly with -19 increasing concentrations. The recovery values for Caco-2 transport of Aliskiren (1, 5, 10 and 50 pM) are generally very high (<100 %), indicating that Aliskiren does not bind to the filter support or the plastic incubation environment. Apical to basolateral flux for the paracellular marker Mannitol and the transcellular marker Propranolol are always below the threshold Pp values of 3-10-5 cm/min and 90-10~5 cm/min, respectively. The determined apical to basolateral filter permeabilities are generally higher than the corresponding Caco-2 permeability data, indicating filter diffusion not to be the rate limiting step for Caco-2 transport (Figures 2). The reference in this specification to any prior publication (or information derived from it), or to any matter which is known, is not, and should not be taken as an acknowledgment or admission or any form of suggestion that that prior publication (or information derived from it) or known matter forms part of the common general knowledge in the field of endeavour to which this specification relates. Throughout this specification and the claims which follow, unless the context requires otherwise, the word "comprise", and variations such as "comprises" and "comprising", will be understood to imply the inclusion of a stated integer or step or group of integers or steps but not the exclusion of any other integer or step or group of integers or steps.

Claims

1. A pharmaceutical composition comprising (i) a renin inhibitor and (ii) an MDR1 inhibitor selected from a non-pharmacologically active 5 compound, wherein the non-pharmacologically active compound is a GRAS compound selected from the group consisting of curcumin, phenyl cinnamate, coumarin, beta-amyrin cinnamate, apiole, bergamottin, caffein, 8-(decylthio-)caffeine, 8-benzyl-caffeine, diethylpyrocarbonate, morin, narirutin, piperine, quercetin, salvinorin, silybin, 10 theobromin, vanillin, and vanillyl-N-nonylamide.

2. The pharmaceutical composition according to claim 1 wherein the non pharmacologically active compound is selected from Curcumin, Piperine, Coumarin, and Phenyl cinnamate.

3. The pharmaceutical composition according to claim 1 or 2, wherein the renin 15 inhibitor is a S-amino-y-hydroxy-o-aryl-alkanoic acid amide derivative, or a pharmaceutically acceptable salt thereof.

4. The pharmaceutical composition according to claim 3, wherein the S-amino-y hydroxy-o-aryl-alkanoic acid amide derivative has the formula OH R4H H2N,,,, N NH2 R2 R3 20 wherein R 1 is Cl4alkoxy-Cl 4 alkoxy or C1.4alkoxy-C1.4alkyl; R 2 is C1.4alkyl or C 1 . 4 alkoxy; and R 3 and R 4 are independently branched C 1 . 4 alkyl; or a pharmaceutically acceptable salt thereof. C INRPonbrDCC\SZP\3153828 I DOC-8/31/2010 - 21 5. The pharmaceutical composition according to claim 3 or 4, wherein the S-amino-y hydroxy-co-aryl-alkanoic acid amide derivative is a compound of formula (1) wherein R 1 is 3-methoxypropoxy; R 2 is methoxy; and R 3 and R 4 are isopropyl; or a pharmaceutically acceptable salt thereof.

5

6. The pharmaceutical composition according to Claim 5, wherein the S-amino-y hydroxy-co-aryl-alkanoic acid amide derivative is (2S,4S,5S,7S)-5-amino-4-hydroxy-2 isopropyl-7-[4-methoxy-3-(3-methoxy-propoxy)-benzyl]-8-methyl-nonanoic acid (2 carbamoyl-2-methyl-propyl)-amide hemifumarate.

7. A method of improving the bioavailability of a renin inhibitor, which method 10 comprises co-administering, to a mammal in need such treatment, a combination of a renin inhibitor and an MDR1 inhibitor selected from a non-pharmacologically active compound, wherein the non-pharmacologically active compound is a GRAS compound selected from the group consisting of curcumin, phenyl cinnamate, coumarin, beta-amyrin cinnamate, apiole, bergamottin, caffein, 8-(decylthio-)caffeine, 15 8-benzyl-caffeine, diethylpyrocarbonate, morin, narirutin, piperine, quercetin, salvinorin, silybin, theobromin, vanillin, and vanillyl-N-nonylamide.

8. The method according to claim 7 wherein the non-pharmacologically active compound is selected from Curcumin, Piperine, Coumarin, and Phenyl cinnamate.

9. The method according to claim 7 or 8, wherein the renin inhibitor is a 8-amino-y 20 hydroxy-o-aryl-alkanoic acid amide derivative, or a pharmaceutically acceptable salt thereof.

10. The method according to claim 9, wherein the 8-amino-y-hydroxy-o-aryl-alkanoic acid amide derivative has the formula OH R4H H2N,,,N NH2 R, O O 2 R C VNRPortblDCCISZP\3153828.1.DOC-8/3112010 - 22 wherein R 1 is Cl4alkoxy-Cl4alkoxy or C 1 .4alkoxy-C 1 . 4 alkyl; R 2 is C14alkyl or C 1 . 4 alkoxy; and R 3 and R 4 are independently branched C1.4alkyl; or a pharmaceutically acceptable salt thereof.

11. The method according to claim 10, wherein the S-amino-y-hydroxy-o-aryl-alkanoic 5 acid amide derivative is a compound of formula (1) wherein R 1 is 3-methoxypropoxy; R 2 is methoxy; and R 3 and R 4 are isopropyl; or a pharmaceutically acceptable salt thereof.

12. The method according to claim 11, wherein the S-amino-y-hydroxy-o-aryl-alkanoic acid amide derivative is (2S,4S,5S,7S)-5-amino-4-hydroxy-2-isopropyl-7-[4-methoxy-3-(3 methoxy-propoxy)-benzyl]-8-methyl-nonanoic acid (2-carbamoyl-2-methyl-propyl)-amide 10 hemifumarate.

13. The use of an MDR1 inhibitor selected from a non-pharmacologically active compound in the manufacture of a medicament for improving the bioavailability of a renin inhibitor, or a pharmaceutically acceptable salt thereof, wherein the non pharmacologically active compound is a GRAS compound selected from the group 15 consisting of curcumin, phenyl cinnamate, coumarin, beta-amyrin cinnamate, apiole, bergamottin, caffein, 8-(decylthio-)caffeine, 8-benzyl-caffeine, diethylpyrocarbonate, morin, narirutin, piperine, quercetin, salvinorin, silybin, theobromin, vanillin, and vanillyl-N-nonylamide.

14. The use according to claim 13 wherein the non-pharmacologically active 20 compound is selected from Curcumin, Piperine, Coumarin, and Phenyl cinnamate.

15. The use according to claim 13 or 14, wherein the renin inhibitor is a S-amino-y hydroxy-o-aryl-alkanoic acid amide derivative, or a pharmaceutically acceptable salt thereof.

16. The use according to claim 15, wherein the 8-amino-y-hydroxy-co-aryl-alkanoic acid 25 amide derivative has the formula C:WRPortb(DCC\SZP\3153828_1.DOC-8/31/2010 - 23 OH R4 H2,, NH 2 RI 0 0 R 2 R3 wherein R 1 is Cl-alkoxy-Cl-alkoxy or Cl4alkoxy-Cl. 4 alkyl; R 2 is C1.4alkyl or C 1 . 4 alkoxy; and R 3 and R 4 are independently branched C 1 -alkyl; or a pharmaceutically acceptable salt thereof. 5

17. The use according to claim 16, wherein the S-amino-y-hydroxy-o-aryl-alkanoic acid amide derivative is a compound of formula (1) wherein R 1 is 3-methoxypropoxy; R 2 is methoxy; and R 3 and R 4 are isopropyl; or a pharmaceutically acceptable salt thereof.

18. The use according to claim 17, wherein the 6-amino-y-hydroxy-o-aryl-alkanoic acid amide derivative is (2S,4S,5S,7S)-5-amino-4-hydroxy-2-isopropyl-7-[4-methoxy-3-(3 10 methoxy-propoxy)-benzyl]-8-methyl-nonanoic acid (2-carbamoyl-2-methyl-propyl)-amide hemifumarate.

19. The pharmaceutical composition according to claim 1, the method according to claim 7, or the use according to claim 13, substantially as hereinbefore described with reference to any one of the examples.